Care Plans & Priority Care
A nurse explains to a student that the nursing process is a dynamic process. Which of the following actions by the nurse best demonstrates this concept during the work shift?
A. Nurse and client agree upon health care goals for the client
B. Nurse reviews the client's history on the medical record
C. Nurse explains to the client the purpose of each administered medication
D. Nurse rapidly reset priorities for client care based on a change in the client's condition
D. Nurse rapidly reset priorities for client care based on a change in the client's condition
Rationale: The nursing process is characterized by unique properties that enable it to respond to the changing health status of the client. Options 1, 2, and 3 are appropriate nursing care measures, but do not demonstrate the dynamic nature of the nursing process.
A client admitted to the hospital with chest pain and a history of type 2 diabetes mellitus is scheduled for cardiac catheterization. Which medication would need to be withheld for 24 hours before the procedure and for 48 hours after the procedure?
1. Regular insulin
2. Glipizide (Glucotrol)
3. Repaglinide (Prandin)
4. Metformin (Glucophage)
4.
Metformin (Glucophage) needs to be withheld 24 hours before and for 48 hours after cardiac catheterization because of the injection of contrast medium during the procedure. If the contrast medium affects kidney function, with metformin in the system, the client would be at increased risk for lactic acidosis. The medications in the remaining options do not need to be withheld 24 hours before and 48 hours after cardiac catheterization.
A 45-year-old man with asthma is brought to the emergency department by automobile. He is short of breath and appears frightened. During the initial nursing assessment, which clinical manifestation might be present as an early manifestation during an exacerbation of asthma?
A. Anxiety
B. Cyanosis
C. Bradycardia
D. Hypercapnia
A.
An early manifestation during an asthma attack is anxiety because the patient is acutely aware of the inability to get sufficient air to breathe. He will be hypoxic early on with decreased PaCO2 and increased pH as he is hyperventilating. If cyanosis occurs, it is a later sign. The pulse and blood pressure will be increased.
A nurse accidently gives a patient the medications that were ordered for the patient's roommate. What is the nurse's first priority?
A. Complete an occurrence report.
B. Notify the health care provider.
C. Inform the charge nurse of the error.
D. Assess the patient for adverse effects.
D. Assess the patient for adverse effects.
The nurse is caring for a patient with osteoporosis who is being discharged on alendronate (Fosamax). Which statement would indicate effective teaching?
A. "I should take the medication immediately before bed"
B. "I should remain in an upright position for 30 minutes after taking the medication"
C. "The medication is more effective if I take it with milk or dairy products"
D. If I skip a dose, I can take two tablets the next time"
Answer: B- Rationale should remain upright for 30 mins.
The client reports nausea and constipation. Which of the following would be the priority nursing action?
A. Collect a stool sample
B. Complete an abnormal assessment
C. Administer an anti-nausea medication
D. Notify the physician
B. Complete an Abdominal assessment
Rationale: Assessment involves the systematic collection of data about an individual upon which all subsequent phases of the nursing process are built. In response to a client's complaint, a nurse assesses a specific body system to obtain data that will help the nurse make a nursing diagnosis and plan the client's care. The other options reflect interventions, which are not timely unless there is first a complete assessment.
The nurse is reviewing an electrocardiogram rhythm strip. The P waves and QRS complexes are regular. The PR interval is 0.16 second, and QRS complexes measure 0.06 second. The overall heart rate is 64 beats/minute. Which would be a correct interpretation based on these characteristics?
1.Sinus bradycardia
2.Sick sinus syndrome
3.Normal sinus rhythm
4.First-degree heart block
3.
Normal sinus rhythm is defined as a regular rhythm, with an overall rate of 60 to 100 beats/minute. The PR and QRS measurements are normal, measuring 0.12 to 0.20 second and 0.04 to 0.10 second, respectively.
Which position is most appropriate for the nurse to place a patient experiencing an asthma exacerbation?
A. Supine
B. Lithotomy
C. High Fowler's
D. Reverse Trendelenburg
C,
The patient experiencing an asthma attack should be placed in high Fowler's position and may need to lean forward to allow for optimal chest expansion and enlist the aid of gravity during inspiration. The supine, lithotomy, and reverse Trendelenburg positions will not facilitation ventilation.
After seeing a patient, the health care provider starts to give a nursing student a verbal order for a new medication. The nursing student first needs to:
A. Follow ISMP guidelines for safe medication abbreviations.
B. Explain to the health care provider that the order needs to be given to a registered nurse.
C. Write down the order on the patient's order sheet and read it back to the health care provider.
D. Ensure that the six rights of medication administration are followed when giving the medication.
B. Explain to the health care provider that the order needs to be given to a registered nurse.
The nurse is performing an assessment on an older adult patient and observes the patient has an increased forward curvature of the thoracic spine What does the nurse understand this common finding is known as?
A.Lordosis
B.Scoliosis
C.Osteoporosis
D.Kyphosis
Rationale: Answer D is correct.
Which of the following descriptors is most appropriate to use when stating the "problem" part of a nursing diagnosis?
A. Grimacing
B. Anxiety
C. Oxygenation saturation 93%
D. Output 500 mL in 8 hours
B. Anxiety
Rationale: The problem part of a nursing diagnosis should state the client's response to a life process, event, or stressor. These are categorized as nursing diagnoses. The incorrect options are cues the nurse would use to formulate the nursing diagnostic statement.
A client is wearing a continuous cardiac monitor, which begins to sound its alarm. A nurse sees no electrocardiographic complexes on the screen. Which is the priority action of the nurse?
1.Call a code.
2.Call the health care provider.
3.Check the client's status and lead placement.
4.Press the recorder button on the electrocardiogram console.
3.
Sudden loss of electrocardiographic complexes indicates ventricular asystole or possibly electrode displacement. Accurate assessment of the client and equipment is necessary to determine the cause and identify the appropriate intervention. The remaining options are secondary to client assessment.
The nurse determines that the patient understood medication instructions about the use of a spacer device when taking inhaled medications after hearing the patient state what as the primary benefit?
A. "I will pay less for medication because it will last longer."
B. "More of the medication will get down into my lungs to help my breathing."
C. "Now I will not need to breathe in as deeply when taking the inhaler medications."
D. "This device will make it so much easier and faster to take my inhaled medications."
C.
A spacer assists more medication to reach the lungs, with less being deposited in the mouth and the back of the throat. It does not affect the cost or increase the speed of using the inhaler.
A pediatric nurse takes a medication to a 12-year-old female patient. The patient tells the nurse to take it away because she is not going to take it. What is the nurse's next action?
A. Ask the patient's reason for refusal
B. Consult with the patient's parents for advice
C. Take the medication away and chart the patient's refusal
D. Tell the patient that her health care provider knows what is best for her
A. Ask the patient's reason for refusal
To prevent dislocation of a hip prosthesis following a total hip replacement, the nurse should:
A. Maintain the patient's affected leg in an adducted position
B. Maintain the patient's affected hip in a flexed position
C. Tell the patient to remain in supine position
D. Place an abduction pillow between the patient's leg
Rationale: Answer D is correct. The patient's leg should be maintained in an abducted position to prevent dislocation of the prosthesis. This is accomplished by the use of an abduction pillow. Answers A and B will increase the likelihood of dislocation of the prosthesis; therefore, they are incorrect. Answer C is unnecessary; therefore, it is incorrect.
Which of the following items of subjective client data would be documented in the medical record by the nurse?
A. Client's face is pale
B. Cervical lymph nodes are palpable
C. Nursing assistant reports client refused lunch
D. Client feel nauseated
D. Client feel nauseated
Rationale: Subjective data includes the client's sensations, feelings, and perception of health status. Subjective data can only be verified by the affected person. Options 1, 2, and 3 represent objective data that can be detected by the nurse or measured against an accepted norm.
The nurse is evaluating a client's response to cardioversion. Which observation would be of highest priority to the nurse?
1.Blood pressure
2.Status of airway
3.Oxygen flow rate
4.Level of consciousness
2.
Nursing responsibilities after cardioversion include maintenance first of a patent airway, and then oxygen administration, assessment of vital signs and level of consciousness, and dysrhythmia detection.
During an assessment of a 45-year-old patient with asthma, the nurse notes wheezing and dyspnea. The nurse interprets that these symptoms are related to what pathophysiologic change?
a. Laryngospasm
b. Pulmonary edema
c. Narrowing of the airway
d. Overdistention of the alveoli
C
Narrowing of the airway by persistent but variable inflammation leads to reduced airflow, making it difficult for the patient to breathe and producing the characteristic wheezing.
Laryngospasm, pulmonary edema, and overdistention of the alveoli do not produce wheezing.
The nurse is preparing 10 units of regular insulin and 5 units of NPH insulin. Which of the following statements is the most accurate?
A. The NPH insulin is the shortest acting form of insulin.
B. Air is injected first into the regular insulin, then into the NPH.
C. The insulin vial should be discarded if there are any bubbles in it.
D. This medication order is given via the subcutaneous route.
D. This medication order is given via the subcutaneous route.
An elderly female is admitted with a fractured right femoral neck. Which assessment finding is expected?
A. Free movement of the right leg
B. Abduction of the right leg
C. Internal rotation of the right hip
D. Shortening of the right leg
An elderly female is admitted with a fractured right femoral neck. Which assessment finding is expected?
A. Free movement of the right leg
B. Abduction of the right leg
C. Internal rotation of the right hip
D. Shortening of the right leg
Rationale: Answer D is correct. The symptoms of this fracture include shortened, adducted, and external rotation. Answer A is incorrect because the patient usually is unable to move the leg due to pain. Answer B is incorrect because the symptom is adduction, not abduction. Answer C is wrong because it's external rotation, not internal rotation.
The nurse notes that the client often sighs and says in a monotone voice, "I'm never going to get over this." When encouraged to participate in care, the client says, "I don't have the energy." The nurse believes these cues are suggestive of which nursing diagnoses? Select all that apply.
A. Hopelessness
B. Powerlessness
C. Interrupted sleep pattern
D. Disturbed self esteem
E. Self care deficit
A. Hopelessness
B. Powerlessness
Rationale: Rationale: A nursing diagnosis is a clinical judgment about a response to an actual or potential health problem. This client is manifesting symptoms of both hopelessness and powerlessness. Although the client does report symptoms compatible with fatigue, there is no direct data is given that indicates the client has interrupted sleep patterns (option 3), disturbed self esteem (option 4), or self care deficit (option 5).
The nurse is providing instructions to a client with a diagnosis of hypertension regarding high-sodium items to be avoided. The nurse instructs the client to avoid consuming which item?
1.Bananas
2.Broccoli
3.Antacids
4.Cantaloupe
3.
The sodium level can increase with the use of several types of products, including toothpaste and mouthwash; over-the-counter medications such as analgesics, antacids, laxatives, and sedatives; and softened water and mineral water. Clients are instructed to read labels for sodium content. Water that is bottled, distilled, deionized, or demineralized may be used for drinking and cooking. Fresh fruits and vegetables are low in sodium.
The patient has an order for each of the following inhalers. Which one should the nurse offer to the patient at the onset of an asthma attack?
A. Albuterol (Proventil)
B. Salmeterol (Serevent)
C. Beclomethasone (Qvar)
D. pratropium bromide (Atrovent)
A.
Albuterol is a short-acting bronchodilator that should be given initially when the patient experiences an asthma attack. Salmeterol (Serevent) is a long-acting β2-adrenergic agonist, which is not used for acute asthma attacks. Beclomethasone (Qvar) is a corticosteroid inhaler and not recommended for an acute asthma attack. Ipratropium bromide (Atrovent) is an anticholinergic agent that is less effective than β2-adrenergic agonists. It may be used in an emergency with a patient unable to tolerate short-acting β2-adrenergic agonists (SABAs).
A clinet is nauseated, has been vomiting for several hours, and needs to receive an antiemetic (anti-nausea) medication. Which of the following is accurate?
A. An enteric-coated medication should be given.
B. Any medication will not be absorbed as easily because of the nausea problem.
C. A parenteral route is the route of choice.
D. A rectal suppository must be administered.
C. A parenteral route is the route of choice.
A retired 66- year- old female patient is being evaluated for osteoporosis as part of a yearly physical exam. The patient states that she is a smoker, watches television for most of the day, and has been hospitalized twice with fractures within the last year. Based on this information, the nurse suspects which condition?
A.Low bone mass leading to increased bone fragility
B.Degeneration of the articular cartilage
C.Recurrent attacks of acute arthritis
D.Personality changes caused by chronic nature of illness
A. Low bone mass leading to increased bone fragility
'
Low bone mass, structural deterioration of bone tissue leading to bone fragility, and increased susceptibility to fractures are seen with osteoporosis. The patient also has risk factors associated with osteoporosis: smoking, sedentary lifestyle, and being female and menopausal. Degenerative changes are associated with frequent exacerbations of arthritis. There is no indication of personality change in this patient.